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Clinical Ophthalmology (Auckland, N.Z.) 2016Transient vision loss may indicate underlying vascular disease, including carotid occlusion and thromboembolism, or it may have a more benign etiology, such as migraine... (Review)
Review
Transient vision loss may indicate underlying vascular disease, including carotid occlusion and thromboembolism, or it may have a more benign etiology, such as migraine or vasospasm. This review focuses on the differential diagnosis and workup of patients presenting with transient vision loss, focusing on several key areas: the relationship to thromboembolic vascular disease, hypercoagulable testing, retinal migraine, and bilateral vision loss. The objective is to provide the ophthalmologist with information on how to best manage these patients. Thromboembolic etiologies for transient vision loss are sometimes managed with medications, but when carotid surgery is indicated, earlier intervention may prevent future stroke. This need for early treatment places the ophthalmologist in the important role of expediting the management process. Hospital admission is recommended in patients presenting with transient symptoms within 72 hours who meet certain high-risk criteria. When the cause is giant cell arteritis, ocular ischemic syndrome, or a cardioembolic source, early management of the underlying condition is equally important. For nonthromboembolic causes of transient vision loss such as retinal migraine or retinal vasospasm, the ophthalmologist can provide reassurance as well as potentially give medications to decrease the frequency of vision loss episodes.
PubMed: 26929593
DOI: 10.2147/OPTH.S94971 -
Joint Bone Spine May 2012Giant cell arteritis (GCA) affects middle-sized or large arteries in individuals over 50 years of age. GCA is characterized by a combination of focal inflammation... (Review)
Review
Giant cell arteritis (GCA) affects middle-sized or large arteries in individuals over 50 years of age. GCA is characterized by a combination of focal inflammation responsible for arterial stenosis or occlusion and of systemic inflammation manifesting as polymyalgia rheumatica, a decline in general health, and inflammatory anemia. In addition to the typical involvement of the branches of the external carotid arteries, relatively common sites of involvement include the aorta, most notably in its thoracic segment, and the subclavian, axillary, brachial, vertebral, and femoral arteries. The treatment of GCA rests on daily glucocorticoid administration, which should be started on an emergency basis in patients with incipient visual impairments (diplopia or amaurosis fugax). The duration of glucocorticoid therapy is unpredictable and side effects are common. Initial megadose glucocorticoid therapy does not decrease subsequent glucocorticoid requirements. Glucocorticoid therapy regulates the Th17 pathway, which is involved in the prominent vascular and systemic manifestations; but not the Th1 pathway, which may underlie the chronic course of the disease (whereas aspirin, in addition to decreasing platelet aggregation, blocks the Th1 mediator interferon-gamma). Although GCA is classically described as resolving within 1 to 3 years, clinical practice often teaches otherwise. Many patients experience rebound abnormalities in laboratory tests and/or relapses, and some of them have recurrences after an apparently full recovery. Histological documentation is useful to confirm the diagnosis. The effect of methotrexate and TNFα antagonists is modest at best. A few patients have responded to tocilizumab, which suppresses IL-6, a key cytokine in GCA. Life expectancy in GCA patients is similar to that in same-age controls except for a slight excess in vascular mortality shortly after the diagnosis.
Topics: Antibodies, Monoclonal, Humanized; Giant Cell Arteritis; Glucocorticoids; Humans; Immunosuppressive Agents; Interleukin-6
PubMed: 22119350
DOI: 10.1016/j.jbspin.2011.09.015 -
Radiology Oct 2022Background MRI and fluorine 18-labeled sodium fluoride (F-NaF) PET can be used to identify features of plaque instability, rupture, and disease activity, but large... (Observational Study)
Observational Study
Background MRI and fluorine 18-labeled sodium fluoride (F-NaF) PET can be used to identify features of plaque instability, rupture, and disease activity, but large studies have not been performed. Purpose To evaluate the association between F-NaF activity and culprit carotid plaque in acute neurovascular syndrome. Materials and Methods In this prospective observational cohort study (October 2017 to January 2020), participants underwent F-NaF PET/MRI. An experienced clinician determined the culprit carotid artery based on symptoms and record review. F-NaF uptake was quantified using standardized uptake values and tissue-to-background ratios. Statistical significance was assessed with the Welch, χ, Wilcoxon, or Fisher test. Multivariable models were used to evaluate the relationship between the imaging markers and the culprit versus nonculprit vessel. Results A total of 110 participants were evaluated (mean age, 68 years ± 10 [SD]; 70 men and 40 women). Of the 110, 34 (32%) had prior cerebrovascular disease, and 26 (24%) presented with amaurosis fugax, 54 (49%) with transient ischemic attack, and 30 (27%) with stroke. Compared with nonculprit carotids, culprit carotids had greater stenoses (≥50% stenosis: 30% vs 15% [ = .02]; ≥70% stenosis: 25% vs 4.5% [ < .001]) and had increased prevalence of MRI-derived adverse plaque features, including intraplaque hemorrhage (42% vs 23%; = .004), necrotic core (36% vs 18%; = .004), thrombus (7.3% vs 0%; = .01), ulceration (18% vs 3.6%; = .001), and higher F-NaF uptake (maximum tissue-to-background ratio, 1.38 [IQR, 1.12-1.82] vs 1.26 [IQR, 0.99-1.66], respectively; = .04). Higher F-NaF uptake was positively associated with necrosis, intraplaque hemorrhage, ulceration, and calcification and inversely associated with fibrosis ( = .04 to < .001). In multivariable analysis, carotid stenosis at or over 70% (odds ratio, 5.72 [95% CI: 2.2, 18]) and MRI-derived adverse plaque characteristics (odds ratio, 2.16 [95% CI: 1.2, 3.9]) were both associated with the culprit versus nonculprit carotid vessel. Conclusion Fluorine 18-labeled sodium fluoride PET/MRI characteristics were associated with the culprit carotid vessel in study participants with acute neurovascular syndrome. Clinical trial registration no. NCT03215550 and NCT03215563 © RSNA, 2022
Topics: Aged; Carotid Arteries; Constriction, Pathologic; Female; Fluorine; Fluorine Radioisotopes; Humans; Magnetic Resonance Imaging; Male; Plaque, Atherosclerotic; Positron-Emission Tomography; Prospective Studies; Sodium Fluoride
PubMed: 35670715
DOI: 10.1148/radiol.212283 -
Journal of Vascular Surgery Jan 2020Carotid endarterectomy (CEA) is a well-established procedure with prospective randomized data demonstrating the benefit of stroke prevention. With the aging of the...
OBJECTIVE
Carotid endarterectomy (CEA) is a well-established procedure with prospective randomized data demonstrating the benefit of stroke prevention. With the aging of the population, there are limited data published for nonagenarians, especially for asymptomatic stenosis. This study investigated 30-day morbidity and mortality as well as late survival in symptomatic and asymptomatic nonagenarians with severe carotid stenosis undergoing CEA.
METHODS
A retrospective review was conducted of a single vascular surgery group's registry involving multiple hospitals between November 1994 and June 2017 for all primary CEAs of patients ≥90 years old at the time of surgery. The exclusion criterion was redo surgery or bilateral CEAs. Demographic data, sex, symptoms, risk factors, and postoperative complications were analyzed. Survival analysis was conducted using SPSS software (IBM Corp, Armonk, NY) for the specific end point 30-day morbidity or mortality and late survival.
RESULTS
There were 77 patients (44 male [57%]) who underwent CEA for symptomatic (44 [57%]) and asymptomatic (33 [43%]) internal carotid artery stenosis with a median age of 92 years; 23 women were symptomatic compared with 21 men, and 23 men were asymptomatic compared with 10 women. Symptomatic patients included amaurosis fugax (n = 3), stroke (n = 16), and transient ischemic attack (n = 25). CEAs were performed using the eversion technique under cervical block with selective shunting. The 30-day morbidity included one (2.3%) nonfatal myocardial infarction and one (2.3%) ischemic stroke in the symptomatic group compared with one (3%) patient having a nonfatal myocardial infarction and none with ischemic stroke in the asymptomatic group. One patient of the symptomatic group required return to the operating room for hematoma evacuation. The 30-day mortality was 2.3% in the symptomatic group compared with 6.1% in the asymptomatic group. There was no statistical difference in survival based on sex (P = .444). The symptomatic and asymptomatic groups had similar median survival of 27.7 months and 29.4 months (P = .987), respectively.
CONCLUSIONS
The aging population adds increasing difficulty in decision-making for surgical intervention on carotid stenosis. CEA in nonagenarians is associated with reasonably low 30-day rates of ischemic stroke and myocardial infarction in our small study. However, enthusiasm for asymptomatic CEA in this population must be tempered by low survival rates.
Topics: Age Factors; Aged, 80 and over; Asymptomatic Diseases; Brain Ischemia; Carotid Stenosis; Clinical Decision-Making; Endarterectomy, Carotid; Female; Humans; Male; Myocardial Infarction; Patient Selection; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome
PubMed: 31611107
DOI: 10.1016/j.jvs.2019.07.083 -
American Journal of Ophthalmology Case... Sep 2017To describe the importance of considering vaso-occlusive disease on the differential diagnosis of a patient presenting with amaurosis fugax (AF) and unilateral cotton...
PURPOSE
To describe the importance of considering vaso-occlusive disease on the differential diagnosis of a patient presenting with amaurosis fugax (AF) and unilateral cotton wool spots (CWS).
OBSERVATIONS
A 69-year-old female with history of obesity, hyperlipidemia and recent orthopedic surgery, presented with 3 days of worsening monocular AF and CWS in the right eye. She was diagnosed with antiphosphospholipid syndrome based on positive serologic testing for antiphosphatidylserine IgM, anticardiolipin IgM. The patient was treated with lipid lowering medication, long-term aspirin, and has followed a weightloss and physical therapy program under medical supervision. The CWS resolved and AF symptoms have not recurred.
CONCLUSIONS AND IMPORTANCE
Antiphospholipid syndrome can be considered in the differential diagnosis of patients presenting with AF, assymetric CWS, and/or rapid progression of symptoms.
PubMed: 29260101
DOI: 10.1016/j.ajoc.2017.07.005 -
The Western Journal of Medicine Mar 1975
PubMed: 18747509
DOI: No ID Found -
Clinical Reviews in Allergy & Immunology Aug 2003The classical clinical picture of the antiphospholipid syndrome (APS) is characterized by venous and arterial thromboses, fetal losses and thrombocytopenia, in the... (Review)
Review
The classical clinical picture of the antiphospholipid syndrome (APS) is characterized by venous and arterial thromboses, fetal losses and thrombocytopenia, in the presence of antiphospholipid antibodies (aPL), namely lupus anticoagulant (LA), anticardiolipin antibodies (aCL), or antibodies to the protein "cofactor" b2 glycoprotein I. Single vessel involvement or multiple vascular occlusions may give rise to a wide variety of presentations. Any combination of vascular occlusive events may occur in the same individual and the time interval between them also varies considerably from weeks to months or even years. Deep vein thrombosis, sometimes accompanied by pulmonary embolism, is the most frequently reported manifestation in this syndrome. Cerebrovascular accidents-either stroke or transient ischemic attacks-are the most common arterial thrombotic manifestations. Early and late fetal losses, premature births and pre-eclampsia are the most frequent fetal and obstetric manifestations. Additionally, several other clinical features are relatively common in these patients, i.e., thrombocytopenia, livedo reticularis, heart valve lesions, hemolytic anemia, epilepsy, myocardial infarction, leg ulcers, and amaurosis fugax. However, a large variety of other clinical manifestations have been less frequently described in patients with the APS, with prevalences lower than 5%. These include, among others, large peripheral or aortic artery occlusions, Sneddon's syndrome, chorea, transverse myelopathy, intracardiac thrombus, adult respiratory distress syndrome, renal thrombotic microangiopathy, Addison's syndrome, Budd-Chiari syndrome, nodular regenerative hyperplasia of the liver, avascular necrosis of the bone, cutaneous necrosis or subungual splinter hemorrhages. In this article, some of these "unusual" manifestations are reviewed.
Topics: Antiphospholipid Syndrome; Humans; Prevalence; Pulmonary Embolism; Stroke; Venous Thrombosis
PubMed: 12794262
DOI: 10.1385/CRIAI:25:1:61 -
Journal of Neurology, Neurosurgery, and... Feb 2003
Topics: Amaurosis Fugax; Calcium Channel Blockers; Cyclandelate; Diagnosis, Differential; Humans; Laser-Doppler Flowmetry; Male; Middle Aged; Retinal Artery Occlusion; Vasoconstriction
PubMed: 12531936
DOI: 10.1136/jnnp.74.2.149 -
Journal of Vascular Surgery Apr 2022The current risk assessment for patients with carotid atherosclerosis relies primarily on measuring the degree of stenosis. More reliable risk stratification could...
OBJECTIVE
The current risk assessment for patients with carotid atherosclerosis relies primarily on measuring the degree of stenosis. More reliable risk stratification could improve patient selection for targeted treatment. We have developed and validated a model to predict for major adverse neurologic events (MANE; stroke, transient ischemic attack, amaurosis fugax) that incorporates a combination of plaque morphology, patient demographics, and patient clinical information.
METHODS
We enrolled 221 patients with asymptomatic carotid stenosis of any severity who had undergone computed tomography angiography at baseline and ≥6 months later. The images were analyzed for carotid plaque morphology (plaque geometry and tissue composition). The data were partitioned into training and validation cohorts. Of the 221 patients, 190 had complete records available and were included in the present analysis. The training cohort was used to develop the best model for predicting MANE, incorporating the patient and plaque features. First, single-variable correlation and unsupervised clustering were performed. Next, several multivariable models were implemented for the response variable of MANE. The best model was selected by optimizing the area under the receiver operating characteristic curve (AUC) and Cohen's kappa statistic. The model was validated using the sequestered data to demonstrate generalizability.
RESULTS
A total of 62 patients had experienced a MANE during follow-up. Unsupervised clustering of the patient and plaque features identified single-variable predictors of MANE. Multivariable predictive modeling showed that a combination of the plaque features at baseline (matrix, intraplaque hemorrhage [IPH], wall thickness, plaque burden) with the clinical features (age, body mass index, lipid levels) best predicted for MANE (AUC, 0.79), In contrast, the percent diameter stenosis performed the worst (AUC, 0.55). The strongest single variable for discriminating between patients with and without MANE was IPH, and the most predictive model was produced when IPH was considered with wall remodeling. The selected model also performed well for the validation dataset (AUC, 0.64) and maintained superiority compared with percent diameter stenosis (AUC, 0.49).
CONCLUSIONS
A composite of plaque geometry, plaque tissue composition, patient demographics, and clinical information predicted for MANE better than did the traditionally used degree of stenosis alone for those with carotid atherosclerosis. Implementing this predictive model in the clinical setting could help identify patients at high risk of MANE.
Topics: Biomarkers; Carotid Arteries; Carotid Artery Diseases; Carotid Stenosis; Computed Tomography Angiography; Constriction, Pathologic; Hemorrhage; Humans; Magnetic Resonance Imaging; Plaque, Atherosclerotic
PubMed: 34793923
DOI: 10.1016/j.jvs.2021.10.056